Saturday, October 31, 2009

Malcolm Gladwell has an illuminating article in last week's New Yorker about an entity known as Chronic Traumatic Encephalopathy (CTE) which is a variant of cognitive dementia that develops in people who are subjected to repeated blows to the head (pugilists and football players especially). The article is debased slightly by the usual Gladwellian attempt to make a forced correlation between two seemingly unrelated topics (in this case dogfighting and NFL linemen), but it's a decent read nonetheless.

A recent study from Boston University delineates the pathophysiology of CTE as relating to abnormal deposition of the tau protein (whatever that is). Another study from the University of Michigan reports that former NFL football players develop early onset dementia or memory loss at a rate 19 times higher than the general male population between the ages of 30-49. There was even a sample from a teenage football player whose brain showed abnormal levels of the tau protein.

The bottom line is that football is an extremely dangerous activity. The dog fighter analogy is a stretch but these guys who play professional football for a living are indeed the gladiators of our age. Especially the interior linemen. And none of their contracts are guaranteed, that's the best part. These billionaire owners can cut a guy at any time, for any reason. Injury prone? Too many concussions? Out the door. So these guys play through it. They lace up their pads until they can't physically do it anymore. And too many of them are ending up like Mike Webster after their playing days have ended, sleeping under highway bypasses with all the other bums....

Thursday, October 29, 2009

I haven't read much in the med blogosphere about the so-called doctor fix. Last week, word leaked out that a version of the Democratic health care plan included a provision that would eliminate planned Medicare cuts to physicians as mandated by a 1997 federal law. This law used a complex formula, known as the sustainable growth rate (SGR), to limit federal spending on health care. The idea was to prevent spending on health care from growing faster than the economy. The problem is that spiralling health care costs have in fact grown exponentially faster than the economy. Therefore, as demanded by the SGR formula, doctors should have seen reimbursement cuts of 20-40% over the past few years. Given the tight balance between profitability and bankruptcy that most primary care docs negotiate, such drastic cuts would lead to a near collapse of private practice as a business model. So every year, Congress passes a one time bill that defers those cuts until the next fiscal year. In the most recent iteration of Obamacare 2009, the plan was to completely do away with any future Medicare cuts for the next ten years by subsidizing the cuts with $240 billion of federal money. The problem is that this subsidy was completely unfunded (sort of like GW Bush's prescription benefit bill) and more moderate congressmen went nuts. The idea is now dead in the water.

The whole thing is amusing to me in this respect. Remember when J. James Rohack (President of the AMA) wrote a guest post on Kevin MD enthusiastically supporting Obamacare back in August, mainly because of promises to do away with any future SGR cuts? I can't wait to read his follow up piece. Tort reform gets taken off the table early in the game and our AMA President is ok with it. Because, you see, our noble politicians in Washington promised him that the SGR issue would be "fixed". And this bad faith effort to effect reform by slapping together an absurd plan to simply write off the SGR cuts as unfunded debt for ten years represents an ingenius form of cynicism, even for our wily DC politicos. Of course the plan was going to get panned. Of course public backlash would make passage of the bill impossible. So it's out. And now we're back to square one. Obamacare has moved on, closer than ever to becoming a reality. And it still carries an endorsement from the AMA, even though the giant carrot that warranted that endorsement has been disregarded....

UPDATE:The WSJ Health Blog reports that the doctor fix is still in play, unfunded as before. Only now it's going to be implemented via a separate bill. That way there, Obamacare isn't contaminated by the stigma of having anything in it that will increase the federal debt. I hope Dr Rohack is pleased...

A NY Times op ed from October 10 makes the case that the management of breast cancer ought to be coordinated and run entirely by fellowship trained specialists hereafter to be known as "mammologists". The article was written by an OB/Gyn who runs the breast fellowship program at the University of Rich Rod. Basically, it's another barely camouflaged attempt by a sub-sub specialist to corner the surgical market on a type of operation that is about as straight forward and simple as it gets. (Surgical training programs assign junior residents and interns to all the breast lumpectomies). The decision-making in breast oncology is certainly complex and patients benefit from a multi-disciplinarian approach but the actual surgical procedures are not exactly enigmatic. The idea that you need to have your mastectomy done by an expert, i.e. a "breast surgeon" is rather absurd.

But the article does raise an interesting point. Specifically, why don't OB/Gynes do breast surgery? They do pap smears and pelvic exams and formal breast exams and usually are the ones who order yearly mammograms on their patients. It has always struck me as odd that once breast pathology is identified, the patient is all of a sudden shunted off to a general surgeon.

The super-specialization of surgery is an apparent inevitability. The paradigm of practicing "general surgery" is a dying ideal. I can read the writing on the wall. But these specialists are going to have to do a better job in coming up with new appellations. I mean, "mammologist"? That sounds terrible. It sounds zoologic. Just call yourself a breast surgeon, dammit.

Yeah I know, I haven't been around. It's been a combination of being incredibly busy at work and stressed out and hitting the wall a bit creatively. It happens. Blogging is a demanding endeavor. Don't let anyone tell you anything differently, especially with the format I do (original posts, not much linking). You reach a point throughout the year where you just sort of get sick of hearing yourself opine on various topics. Blogging is intrinsically a narcissistic, self-indulgent hobby; presenting YOUR TAKE on the latest medical controversy for all the world to hear, constantly positioning yourself on various issues, proclaiming your own special stance in an open forum. It's exhausting. But whatever. Blog posts that talk about how tiresome and tough blogging can be are annoying. So I'll stop. I'll start posting again. I have a few things in mind...

Thursday, October 15, 2009

This survey paper from Archives of Surgery in August addresses public/health professional viewpoints on end of life interventions, specifically in situations of severe traumatic injuries ultimately resulting in death. It isn't much of a paper. Surveys are bogus. I think there was only a 50% response rate. But whatever. Here's what I want to highlight:

Most of the public (51.9%) and the professionals (62.7%) would prefer to be present in the treatment room as opposed to the waiting room in the ED during resuscitation of a loved one (Table 2). This preference endured even when respondents may witness disturbing sights. If the victim were a child, the preference for being in the treatment room increased to 79.0% of the public and 78.7% of the professionals.

General impressions can be gleaned, which are often just as useful as meticulously parameterized data. And the general impression of this paper---that both the lay public and health care professionals would prefer to be in a trauma bay during the resuscitation of an traumatically injured child---- is just outlandish to me.

On trauma call one day as a 4th year resident, they rolled in a four year old kid from Chicago's south side who had run out into the street and got drilled by a speeding car (hit and run). He lost his vitals the minute he arrived. He was blond and blue eyed and there was dirt under his fingernails and we were pumping his pale, frail chest and finally the Trauma attending performed an ED thoracotomy. His tiny little pink lung erupted through the wound and his heart fluttered uselessly in its pristine diaphanous sac. There was no blood in the chest. He clamped the aorta and massaged the heart directly. Still no vitals. The next maneuver was a debatable one, in retrospect, but it was almost as if he, all of us in the room collectively, felt the need to do something else, to keep working, anything to avoid stopping, admitting futility. The child's belly had seemed to distend during the resuscitation. So the attending opened up his virgin abdomen, hoping to encounter hemoperitoneum, possibly to clamp the supraceliac aorta, possibly to find a specific injury to repair or at least temporize. There was nothing. The translucent, parchment-thin bowels bulged through the incision. There was no blood. His little liver was beautiful, I remember thinking. Nothing to fix. The vitals never came back and the kid died right there in front of us all with lung and loops of intestines spilled out everywhere. The attending closed the wounds himself, alone, the curtain pulled shut...

I think I put three holes in the call room wall right afterwards. How can something like that happen? For what reason? I still carry the kid's newspaper obituary in my wallet, yellowed and deeply creased after all these years. I take it out every so often. It still pisses me off to this day. I don't want to ever see something like that again...

Wednesday, October 14, 2009

Ted Strickland has placed a halt on any further executions in the state of Ohio pending a full review of the state's lethal injection process. As you may recall, I wrote about the botched execution of convicted murderer Romell Broom last month. Broom has terrible veins and no one was able to establish IV access for the administration of the lethal drug cocktail. After jabbing him for 2 hours, the execution was aborted. For now, all further executions are on hold until the state clarifies how it will handle future access problems.

What the hell is the plan? Is there an ongoing search for an ace IV access professional right now? Are there ads on Craigslist and Monster.com and MDSearch.com?

"Seeking professional vascular access practitioner, qualified and adept in the art of placing temporary vascular access catheters. Must be comfortable performing for a live audience who watch from behind bullet proof glass. Past experience in palliative care and end-of-life management helpful. Leather executioner's hood provided free of charge. Hippocratic oath optional. Would be a government employee. Full benefits included in salary."

Monday, October 12, 2009

Since becoming an Attending Surgeon, I've performed 17 subtotal colectomies (went back and counted) on patients with fulminant c diff colitis over the past three years. As a resident, I don't recall ever doing or even hearing of a patient getting a colectomy for severe c diff. But it's a growing trend. This is a disease entity that didn't exist 15 years ago. Antibiotic induced alteration of colonic bacterial flora allows for overgrowth of this normally non-pathogenic bug. The spectrum of severity is broad, with rare cases (1-5%) progressing to the severe variety of fulminant colitis. What we're finding is that earlier surgical intervention in these severe cases represents the patient's best chance at survival.

There's a good review of fulminant c diff colitis in the May 2009 Archives issue from Harvard. Fulminant colitis is defined by the presence of systemic toxicity. Some salient points:*In-hospital mortality was 35%*Three key indicators of mortality were WBC >35k/bandemia, age >70, cardiopulmonary failure/need for pressors/vent*Earlier surgery was associated with improved survival

The most interesting point was that patient outcomes correlated with which service (surgical vs medicine) that the patient was admitted to. Patients on a surgical service were 3 times more likely to survive fulminant colitis than those patients cared for by the medicine service. They were operated on more frequently and more expeditiously (as one would assume).

So the question is: If fulminant c diff colitis is a surgical disease, shouldn't all patients immediately be transferred to a surgical service once signs of systemic toxicity set in? If the patient is "sick" (renal failure, hypotensive, septic, etc) and has peritonitis on exam, I proceed directly to the OR. Some of these patients I fear are lingering on the medical service with a diagnosis of "infectious colitis" for far too long. Not all c diff is a surgical problem, just like not all cases of acute pancreatitis need to be followed by a surgeon. But it's important to properly stratify these patients and get the surgeon involved sooner rather than later...

Saturday, October 10, 2009

That's a child harmed by an American airstrike in Afghanistan. It's not clear whether this was an unmanned Predator drone that strafed the boy's village. Congratulations to President Obama on the Nobel Peace Prize. Hopefully, the honor will inspire him to embark on a rational strategy that seeks to de-emphasize the "perpetual war state" policy that currently defines our country's foreign affairs. Korea, Vietnam, the proxy wars of Central America in the 80's, Desert Storm, Iraq, and now the interminable 8 year-long Afghanistan misadventure. Isn't it time we lay down our guns for a few years and start to address the serious problems within our borders (health care, post-industrial employment, economic collapse) that threaten us exponentially more than a bunch of Islamic sheep herders and opium lords half way around the world? Just a thought.

CBO Director Doug Elmendorf, never one to acquiese to political pressures, is now stating that medical malpractice reform will lead to over $50 billion in savings over the next ten years. This new claim is based entirely on the premise that defensive medicine has heretofore been underestimated as a source of skyrocketing health care costs. (Previously, atempts to quantify med mal reform were limited to effects on liability insurance premiums). He hints that punitive damages caps ($250,000-$500,000) are a necessary adjunct to any serious attempt at reform.

Now I'm not married to the idea of capping damages. But there's no doubt that physicians in America are driven by fear of potential litigation. It's nice to finally see the federal government acknowledge this reality with objective data...

Wednesday, October 7, 2009

No specialty has been more affected (compromised?) by the notion of work hour reform than general surgery. With the introduction of the 80 hour work week, surgical interns and junior residents saw their hospital contact time cut drastically with deleterious consequences in terms of case load and relative comfort level taking care of typical surgical complications. Other data suggests that errors are paradoxically increased when surgical residents are forced to go home early post call because of continuity of care issues during patient hand offs.

I know I sound like a crotchety old timer, longing for the days of stumbling into my tiny studio apartment in Chicago as an intern with the AC broken, mindlessly whipping up a pan of Kraft mac and cheese, eating directly from pan, and crashing out on the couch with the half eaten mac/cheese on the floor and the TV on and the alarm set to go off at 4:00Am the next morning. Such fond memories indeed. But that sort of regimen made me an anal, relentless, rarely satisfied, tireless surgeon (at least when it comes to patient care). And everyone went through the same thing. So we held each other accountable. It became a way of life (goodbye golf, having beers till 2Am on a random Wednesday in Lincoln Park). And I don't regret it for a minute. I was brainwashed and indoctrinated, most definitely. But I wouldn't be the surgeon I am today without the experience of old school residency. You just can't make up for the lost face time and hours and hours of hours of unfiltered hospital life. There are no books you can read at home to reproduce it. No Youtube videos to watch. No "intensive resident education seminars" that will replace the value of simply spending an ungodly amount of time in the hospital.

One of the arguments for work hour reform is this idea that residents spend too much time doing scut. Scut is the bane of the intern's existence. Go draw a CBC on patient X. Go wheel Mr Y down to cardiology for his stat echocardiogram. Go down to radiology and get hard copies of Mrs M's MRI. Write transfer orders on 6 patients in the ICU. Call the outside hospital to get records of patient G faxed to us by noon. When the senior residents would alight their gaze upon you with that look of "Man, I hate to have to ask you this but..." it's just soul crushing. But you did it. The whole time you're grumbling to yourself about how such mindless toil is beneath you and unworthy of the efforts of someone so highly educated. Is this why I studied so hard all these years?

But a funny thing happens when you spend so much time in the hospital. You find yourself seeing things and experiencing events that change you fundamentally. Little things like chatting with an elderly man while you wheel him down to CT scan, making small talk, learning about him as a human being, rather than simply a name on the list. Watching a veteran nurse in ICU handle a difficult family. Observing how difficult it can be for proud, independent men and women to be thrust into the role of dependent patient, institutionalized, helpless. Seeing the grimace on a patient's face when you're drawing his blood. And there's also the major events. The code blues that are called and you're the only physician around. The post op liver transplant in the ICU who's not doing so well and you end up sitting at her bedside all night, watching the monitors, reacting to the subtle real time alterations in her condition. The emergency colectomy that comes in while all the senior residents are busy doing other cases and you're the only one left to assist. The possibilities are endless. But you have to be present. You have to be in the hospital. The experience is yours, if youre willing to seize it.

You see, there's more to being a doctor/surgeon than just learning how to fix a hernia or run a code. There's a mindset that has to take hold. Call it indoctrination if you like but it's a process that attempts to transform a self-satisfied, smug, well-educated medical student (I certainly fell into that category) into the sort of selfless, compassionate, dedicated, thorough, and mindful physician that we all deserve (a gradual transformation that doesn't end just because you've become an Attending, believe me). The scut work and mindless b.s that junior residents used to have to endure has a lasting effect. One's immersion into the totality of hospital life as a trainee leaves a lifelong mark. Even today, I make my rounds the same way I did when I was an intern. I sit in front of the computer and dutifully write down all the vitals and lab results of my patients in little chicken scratch boxes. I review the xrays and medicine lists. I make up a preliminary plan. And then I go see everyone, one by one. It's very banal and systematic. Nothing's changed, only the degree of ultimate responsibility.

Imagine the military without basic training. Football without two a days in the July heat. Medical school without the grueling second year of no sunlight and 10 hour library sessions. A lot of guys can throw a nice tight spiral on the practice field, but that's not what makes a great quarterback. It's the guy who can make the clutch throws late in the game when he's exhausted, banged up, and all the pressure is on his shoulders. The kinds of people who can perform when the chips are down aren't always born that way. Mental toughness is malleable. And I think that's what Dr. Halsted had in mind when he pioneered the first surgical training program at Johns Hopkins....

Tuesday, October 6, 2009

Dr Waxman's group in Santa Barbara, California has a paper out in Archives this week which makes a strong argument for the Alexis wound retractor when doing an open appendectomy. I use a wound retractor when doing laparoscopic colon resections but I had never heard of anyone using one for an appy. The paper is decent; it's a randomized controlled trial (total of 100 patients or so) comparing wound infection rates with and without the Alexis device. None of the wound-condom patients developed infections while 15% of the cases in the au naturel group were complicated by superficial wound infections.

The device only costs 20 bucks so you're not going to bankrupt the healthcare system by using it. But it just seems a little overwrought to me. Take out the damn appendix laparoscopically if you're worried about wound infections. Much more elegant anyway...

Peter Orszag (OMB chief) comments on the recently released report from the Institute of Medicine averring that over $800 billion is wasted on health care spending. This particular sentence stood out:

Unnecessary services, such as using more expensive brand name drugs when generics are just as good and overusing tests and treatments compared to professional guidelines, account for another $200 billion or so.

Hmm. Doctors are overusing tests and providing unnecessary services, to the tune of $200 billion per year. That sounds a lot like....defensive medicine. But in the subsequent paragraph of his blog post, while delineating possible solutions to the waste problem, not one mention of tort reform from Orszag. Because doctors are greedy bastards, you see. If they are ordering unnecessary tests and procedures(tonsils anyone?) then it must be solely due to financial motivations. Right?

Monday, October 5, 2009

I was reading an interesting article this weekend from the New Yorker about the recent financial collapse. John Cassidy's piece makes the case that the subprime crisis and subsequent implosion was an inevitable consequence of how Wall Street is structured (lack of oversight, disproportionate emphasis on short term profits over long term stability, the "keeping up with the Jones's" mentality of the big investment banks). While discussing possible oversight and consumer protection proposals that would potentially ameliorate future credit crises, this paragraph jumped out at me:

The Administration has also proposed setting up a Consumer Financial Protection Agency, to guard individuals against predatory behavior on the part of banks and other financial firms, but its remit won’t extend to vetting complex securities—like those notorious collateralized debt obligations—that Wall Street firms trade among themselves. Limiting the development of those securities would stifle innovation, the financial industry contends. But that’s precisely the point. “The goal is not to have the most advanced financial system, but a financial system that is reasonably advanced but robust,” Viral V. Acharya and Matthew Richardson, two economists at N.Y.U.’s Stern School of Business, wrote in a recent paper. “That’s no different from what we seek in other areas of human activity. We don’t use the most advanced aircraft to move millions of people around the world. We use reasonably advanced aircrafts whose designs have proved to be reliable.”

The parallels to pharmaceutical/medical device innovation are clear. Do we really need multi-million dollar Da Vinci robots and "incisionless" surgical advances when standard laparoscopy already provides the benefits of minimally invasive, same day surgery? Do we really need the latest combo-hybrid hypertension/cholesterol/diabetes pill when we have older, cheaper, just as effective medicines (whose patents have expired and aren't profitable anymore)? Does the American system of health have to be the most advanced, the most innovative, no matter the cost?

A more pragmatic approach is needed. Innovation and private enterprise have undeniably made our health care system what it is. But a system too dependent on profit margins and the "latest new thingy" is doomed to financial ruin. Laparoscopic cholecystectomy sets a high bar in terms of patient satisfaction and efficacy. Let's stop wasting American ingenuity and capital on making all too subtle, incremental advances (tiny belly button scar to an unseen scar on your vagina) and start focusing on those diseases where quantum leaps in treatments and outcomes are still possible (cancer, transplantation, diabetes, etc).....

Saturday, October 3, 2009

The WSJ reports on the continued employment gains in the health care sector. Over the past year, 300,000 jobs have been created by the ostensibly profligate health care industry. During the same period, non-farm jobs nationwide fell by 6 million.

So obviously we need to cut health care spending right? Or wait a second. Maybe we depend on the fact that we spend 17% of our GDP on healthcare. So maybe we ought to just cut spending in that sector a wee bit. A smidgen perhaps. At least until those steel mills and auto plants and textile factories start churning out product again....

Friday, October 2, 2009

A crushing indictment of the American Torture program was handed down last week in the case of Fouad al-Rabiah by Judge Colleen Kollar-Kotelly. Read the whole story from Andy Worthington here. Trust me. Read it this weekend.

Al-Rabiah was an innocent man picked up in Afghanistan. He worked as a low level employee for Kuwaiti Airlines and was a husband with four children. He also had a history of doing refugee relief work for the Red Crescent. He was picked up (unarmed) by villagers outside Jalalabad in December 2001. Based on testimony from another, unsubstantiated witness, al-Rabiah was transferred to Guatananomo because of allegations that he was an aide to Bin Laden. And he quickly found out that there are no innocent men at Guantanomo. Cheney said so.

Here's what transpired. Al-Rabiah was interrogated initially to no avail. He denied all the accusations brought against him by the unreliable sources. A CIA analyst from 2002 is on record as saying that Al-Rabiah was probably innocent, wrong place at the wrong time. But then he was subjected to the "enhanced interrogation techniques" of Cheneyland and was told that he needed to confess to something because they knew he was guilty. Thinking he would never see his children again otherwise, he "confessed" to numerous charges:

She then moved on to al-Rabiah's own explanations of how he came to make false confessions, noting that he had stated that, shortly after his arrival at Guantánamo, "a senior [redacted] interrogator came to me and said, 'There is nothing against you. But there is no innocent person here. So, you should confess to something so you can be charged and sentenced and serve your sentence and then go back to your family and country, because you will not leave this place innocent.

His interrogators became frustrated, however, as his confessions contained numerous inconsistencies and implausibilities. So he has remained in American custody since then, awaiting a decision on his plea for habeas corpus. And here's the extraordinary thing--- our government's entire case against denying Al-Rabiah habeas corpus is based on the fact that he "confessed" and is therefore a criminal. The Orwellian circularity of the reasoning is just mind boggling. He was presumed guilty. He was told he needed to confess to have any chance at seeing his family again. His confession was so unsubstantiated that even his interrogators didn't believe him and continued to torture him more to get at the "truth". And now our government turns around and uses that confession as their trump card in a trial to justify his continued illegal detention. And these are Department of Justice lawyers from the Obama Administration.

We cannot just turn the page. Accountability is a painful, yet necessary process. The deeper Obama wades into the morass, defending the indefensible, the less distinguishable his legacy becomes from the Cheney/Bush era. He speaks of "moving forward". That's fine. But let's do it with our eyes open for now on. We've betrayed enough core American principles for one generation....

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